The characteristics and outcomes of COVID‐19 among diabetic patients in Wad‐Medani isolation center from September to December 2020: A cross‐sectional study

Abstract Background and Aims Corona virus disease‐19 (COVID‐19) is a recently discovered infection that transmitted briskly worldwide. In this disease (COVID‐19), it was discovered that several disorders, such diabetes, increased the severity and fatality rate. Until now, studies investigating the correlation between diabetes and COVID‐19 in Sudan have not yet been conducted. Thus we aimed to evaluated the characteristics and outcomes of COVID‐19 among diabetic patients Methods A prospective study included 70 diabetic patients with COVID‐19 in Wad‐Medani Isolation Center from September to December 2020. Data concerning demographics and clinical characteristics, as well as outcomes were collected. Results Out of 70 patients, 46 (66%) were men and 24 (34%) were women; the average age was 63 ± 12 years. In diabetes mellitus (DM) types, 69 (98.6%) patient were T2DM. The average of DM duration was 10 ± 6.2 years. Insulin was the major DM medication used by more one‐half of study patients (n = 37; 52.9%). Newly discovered DM after COVD‐19 infection was encountered in 5 (7.1%) patients. Most of the study subjects (n = 44; 63%) had moderately severe form of disease. Hypertension was the commonest comorbid in 29 (41.4%) patients. The intensive care unit admission rate among our study group was 10% (n = 7). The mortality rate among our study patients was found to be 11.4% (n = 8). Dead patients were significantly had high HbA1c levels (11.6 ± 7% vs. 8.8 ± 5%; p = 0.001). Additionally, all individuals with a severe COVID‐19 illness (n = 6; 100%) were dead comparing to no patient died with mild covid illness and 4.5% patients with moderately severe infection (p < 0.001). Conclusion The majority of COVID‐19 diabetic patients were males and older in age. Most of the patients presented with moderate severity and moderately uncontrolled DM. Hypertension was the major comorbidity. The mortality rate was as high as 11.4% and associated with high HbA1c levels and severe form of COVID‐19 as well.

) has quickly transmitted and presented a public health issue. 1,2 As February 25, 2020, the World Health Organization (WHO) proclaimed COVID-19 to be a pandemic and 81,109 laboratory confirmed subjects had been registered globally. 3 Until the time of study writing (August, 2022), over 574 million infected subjects and over 6.3 million deaths have been stated internationally. 4 The first COVID-19 case in Sudan was stated on March 13, 2020 5 and there were more than 63,136 confirmed cases with over 4961 deaths as of August, 2022. 6 The COVID-19 clinical features could be ranged from asymptomatic (17.9%-33.3%) or flu-like presentations to serious condition of acute respiratory failure demanding mechanical ventilation, sepsis and several organ failures. According to evaluations, the mean incubation period is 5.1 days, and most of cases could show symptoms as early as 11.5 days. 7 Diabetes mellitus (DM) is a metabolic disorder with increasing severity over the previous two decades, it's also act as trigger increasing respiratory tract infections. 8 Several works have demonstrated that COVID-19 is correlated to increasing blood glucose levels, especially in elderly DM cases. 9 In one study in Wuhan included 1561 COVID-19 cases, DM was significantly increased the likehood of intensive care unit (ICU) admission and mortality. 10 Also, in British cohort that enrolled 5693 cases, the hazard of fatality was higher among diabetics (p < 0.05), but, the poor outcomes are due to diabetes per se or associated comorbidities still not fully clarified. 11 Up to now, information concerning the clinical characteristics and the outcomes of diabetic COVID-19 subjects was scarce particularly in Sudan. Therefore, this work aimed to evaluate characteristics and outcomes of diabetic COVID-19 Sudanese cases.

| Study design
This is a prospective cross-sectional study conducted in Wad-Medani Isolation Center in Gezira State during the period from September to December 2020.

| Study setting
Wad-Medani Isolation Center is one of the major COVID-19 referral centers found in Gezira State that receives COVID-19 cases from the Central Sudan states. Inside this center, there are 65 beds for mild to moderate patients as 45 beds in general ward as well as 20 beds in high dependency unit. Moreover, this center contains pharmacy, two dialysis units, and a 24-h laboratory.

| Study participants
In this is study a total of 70 adult known or newly diagnosed diabetic patients with COVID-19 diagnosed by defined reverse-transcriptase polymerase chain reaction test by nasopharyngeal swab were recruited. Nondiabetic patients were excluded The diagnosis of known or newly diagnosed DM was performed by oral glucose tolerance test after 75 g anhydrous glucose administration as follow: fasting palms glucose more than 126 mg/ dl, and/or 2-h postprandial glucose more than 199 mg/dl, and/or HbA1c more than 6.5%.

| Data collection
The COVID-19 case report form was created to collect primary clinical data concerning demographics, medical history, clinical symptoms, laboratory findings, and clinical outcomes. Age, gender, DM type, DM duration, use of DM drugs, HbA1c level, comorbidities, COVID-19 severity, length of stay in the ICU, and patient outcome after 3-month follow-up (normally discharged or deceased) were the data used in the current study.

| Ethical approval
Ethical approval obtained from National Research Ethics-review Committee in Sudan Medical Specialization Board. Patients' informed permission and approval from hospital management were also acquired. In attempt to preserve the patient's identity, data utilized privately by using numbers rather than names. The research reports did not mention any specific participants. Only research staff was aware of the patients' identities.
About two-third of patients (n = 44; 63%) presented with moderate COVID-19 infection. The median of hospital stay was found to be 9 days ranged from 1 to 28 days. The characteristics of patients showed in Table 1.

| DISCUSSION
This study aimed to evaluate the characteristics and outcomes of SARS-CoV-2 among 70 diabetic patients in Wad-Medani Isolation Center, Gezira state, Sudan.
Among this study's subjects, DM patients with COVID-19 were commonly males (n = 46; 66%) with a male to female ratio of (1.9:1). Similar results were reported by Chinese study of Li et al. 8 who reported 57.1% of admitted diabetic patients were males. Also, Williamson et al. 11 and Alamin et al. 12 noticed that 52% and 62.5% of diabetic COVID-19 patients were males, respectively.
The average age of our patients was found to be 63 ± 12 years and the majority of them 37 (52.9%) aged above 60 years. Similar results were reported by Alamin et al., 12 Bode et al. 13

and The
Philippine CORONA Study Group 14 those stated that COVID-19 was common among older diabetic patients (>60 years). In the study of Williamson et al., 11 patients with diabetes were found to be 10 years older than non-DM cases.
Insulin was the major DM medication used by more than one-half  In the present study, the mortality rate among our study patients was found to be 11.4% (n = 8). Several mechanisms have been stated for explaining the death among diabetic COVID-19 patients included those specifically correlated to high blood sugar, resulting imbalances, and diabetes-related comorbidities/complications. 21 Our mortality rate was comparable to other previous studies such as Guozhen et al, 19 Guo et al., 22 Wang et al., 23 and Wu et al. 24 where mortality rates were 14.5%, 16%, 10.8%, and 7.3%, respectively. However, higher findings (35.5%) was reported by Onder et al. 25 In attempt to detect the factors influencing fatality in diabetic SARS-CoV-2 patients, poor glycemic control was found to be a significant factor correlated with mortality among those patients as nonsurvived patients were significantly had high HbA1c levels compared to normally discharged patients (11.6 ± 7% vs. 8.8 ± 5%; p = 0.001). It is still unclear whether having poor glycemic control renders COVID-19 individuals at risk for the severe illness, in Giuseppe et al. 26 study the patients with well-controlled blood glucose levels had lesser mortality rates compared to poorly controlled blood glucose levels counterparts (1.1% vs. 11.0%; p = 0.001). Results from a different research also revealed that individuals with T1DM or T2DM who had HbA1c levels greater than 86 mmol/mol (10%) had a higher risk of death than those with HbA1c levels lower than 48 mmol/mol (6.5%). 27

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT
The data used and analyzed during this study are available from the authors on reasonable request.

ETHICS STATEMENT
Ethical approval was obtained from center's ethical committee. Both verbal and written consents to publish this information were gained from the patients.

TRANSPARENCY STATEMENT
The lead author Maali Mustafa affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.